Our Code of Ethics must prohibit physician participation in torture

In the thirty-odd years I have worked with torture survivors, I have heard countless versions of the following story. When Azad* was a 22- year-old university student in his home country, he participated in a public demonstration, criticizing the government’s financial cuts to social programs important to his minority group. He and many other demonstrators were apprehended and brought to a crowded holding centre. They slept on the floor, had limited access to a dirty toilet, and were given a cup of water with a small amount of non-nutritious food twice a day. Azad was taken for interrogation on three occasions. He was accused of having links to terrorist organizations outside the country, and of spreading seditious ideas (his interrogators had found political leaflets in his backpack). They demanded the names of organizers. While being questioned he was struck repeatedly on his back and thighs with police batons, and on the third occasion they beat the soles of his feet. Afterwards he could not walk and had to be dragged back to the holding cell. He was released after five days but expelled from his university.

He was arrested again while postering for an upcoming election. This time, as well as enduring blunt beatings, he was threatened at gunpoint with execution and had his head repeatedly submerged in a tub of dirty water until he lost consciousness. It took his family a month to locate him and gain his release. They decided it was best for him to leave the country.

When I saw Azad, more than a year after his last detention, he was still suffering from daily back pain, knee pain, and a host of psychological symptoms. He was afraid to do physical work or play sports, and was fearful of anyone in uniform. He felt guilty because his family members continued to receive threatening phone calls from people demanding to know his whereabouts. His brother had been fired from his job in the civil service.

To me this is a familiar story of an insecure government using torture to quash dissent, gain information, and punish individuals along with their families and communities. Depending on the person’s resilience and resources, recovery can take more time than one life provides. And so along with many others, my heart sank last winter as I listened to the new U.S. president talk about bringing back torture, “because it works”. Even if Trump’s defense advisers, for now at least, have convinced him to keep torture out of bounds, he has already promoted the destructive message that international and domestic laws prohibiting torture can, and should, be set aside. If the U.S. sustains another 9/11 type of attack, there will be enormous pressures from the White House, sectors of the public, and other agencies to “take the gloves off” once again. Meanwhile, dozens of governments who routinely use torture can do so with added justification.

The American experience post 9/11 illustrates the many ways health professionals can become involved in torture. Although psychologist James Mitchell published his book “Enhanced Interrogation” to defend his role, he clearly describes how he and another psychologist, both with experience in training U.S. military personnel to resist coercive interrogations, led the design and implementation of the CIA techniques, including waterboarding.

CIA medical staff were used to monitor the “rough” interrogations of high value detainees. The U.S. Senate Intelligence Committee Report on Torture includes staff e-mails describing an occasion when an interrogator gave a “xyphoid thrust” to resuscitate a detainee after waterboarding, “with our medical staff edging toward the room”. In an incredibly awkward way, the monitoring role of medical staff was meant to protect interrogators from future charges of torture--the Department of Justice, through a series of memos in 2002, used medical language to argue that the authorized techniques were not torture, as defined in the U.S. criminal code, because the associated pain was not severe enough to be “equivalent in intensity to the pain accompanying organ failure, impairment of bodily function, or even death.”

Further, a 2011 review of medical records and case files published in PLoS Medicine, on behalf of nine detainees who alleged they had been tortured at Guantanamo Bay, showed that physical and psychological injuries consistent with torture had been recorded in their medical charts, but no effort had been made to document the causes of their injuries, amounting to medical collusion and cover-up.

Undoubtedly many of those involved in these actions believed that they were doing the right thing; that exceptional times demanded exceptional responses. James Mitchell wrote: “I decided I had a duty to use what I knew to protect American citizens and our way of life.” Others likely felt they had no choice but to obey their superiors, who presumably knew best. Laws had been interpreted, by the highest legal office in the land, to make legal what any victim and most observers of the techniques would call torture. Which brings us back to the purpose of the Code—in times of heightened fears and conflicting social expectations, the Code provides ethical instruction on how we must act. It informs the public, and our political leaders, on how we willact.

In a crisis, the temptation to use torture to gain information is hard to resist. There is enormous pressure on political leaders and security institutions to protect the public. Criminal laws, moral standards, and concerns about long term negative consequences are set aside. Looking out, the State soon sees hundreds, or thousands, of people who look like my patient, Azad—potential threats who might be usefully tortured. That is why it is so essential to define clear lines of principle at times in our history when clear thinking can still prevail. And that is why, in accordance with international law, the line for torture must explicitly be drawn at none.

*A fictional name; this patient represents a composite of many patients

I have been a Canadian Citizen for just over 50 years. I have lost faith in our medical community and the regulatory process. After my wife was physically tortured by terrorist in India (followed by post-traumatic syndrome would you say?), the CPSO felt it prudent to revoke my licence and put my family including my wife through the mental torture of taking away our only source of income in 1996. It has taken 20 years to recover from the CPSO torture. Here we give refuges red carpet treatment. But we mentally torture our own citizens. Double standards I would say.

The author replies:
I am very sorry to hear about the torture of your wife, which undoubtedly had devastating consequences for her and everyone around her. I am also sorry to hear about your personal loss of faith in our medical community and its regulatory institutions. Without knowing anything about your particular case, it is always true that the integrity of our institutions, like that of our government and all of our social relations, depends on our constant vigilance and willingness to engage in making them better.
Although this article focused on torture, and more narrowly on physician involvement in torture, clearly there are multiple dimensions in which human rights and human equity need to be addressed in our society. To understand the reality of torture, it cannot be seen as an isolated abuse—it is symptomatic of the high level of violence many governments/people are willing to employ to protect their power and their interests. When those same governments articulate ideals of democracy and justice, we are bound to run into double standards and contradictions. It is up to us to challenge injustice where we meet it, and to prevent it if we can.
I would like to challenge the notion that Canada “rolls out the red carpet for refugees”. Although Canada was praised for taking in 46,700 refugees in 2016, the United Nations High Commission for Refugees estimated that 66.5 million people were displaced by violence and persecution that year, 22.5 million of whom fled across international borders. As one of the world’s wealthiest countries, we were not excessively generous. Once in Canada, unless given extra assistance by a private sponsor, refugees are provided with the same supports as citizens who require social assistance. Hovering at or below the poverty line (a reality which should be improved for everyone), they must simultaneously struggle to establish a new life in Canada while coming to terms with the loss of a life and loved ones involuntarily left behind.